Clinical Update
Surgical Smoke
Introduction
Operating room personnel have been exposed to
surgical smoke and aerosol for years without fully
understanding whether they contain hazardous
particles. Not until the introduction and acceptance
of laser surgery technology in the early 1980s did
the constituents of surgical smoke come under
scrutiny. The research to date has focused on four
potential health risks to operating room personnel
and patients: hazardous chemicals, viable viruses,
viable cells, and nonviable particles.
The mechanism of surgical smoke – or plume –
generation by electrosurgery units (ESU) and laser
systems is the same. While being used to cut,
coagulate, vaporize, or ablate tissue, the devices
heat the target cells to the point of boiling causing
the membranes to rupture. This allows odor
causing chemicals and cellular contents including
virus, steam, and fine particles to be dispersed
into the air or pneumoperitoneum. As a result, the
qualities of the surgical smoke generated by these
two methods are very similar. With ultrasonically
activiated devices no burning occurs, but an
aerosol is created.83
• Viable cells and virus are present in surgical
smoke.35-40, 45, 47
• Harmonic Scalpel creates a bioaerosol
containing blood and tissue particles of
respireable size.83
• Particles in surgical smoke cause pathologic
changes and damage to the lungs of rats.61, 62
• Hazards of surgical smoke have been
recognized by AORN, OSHA, NIOSH,
and ANSI.4, 70, 75, 77
• Standard surgical masks are not an effective
barrier.42, 72, 74
While research has not made a direct link between
surgical smoke, aerosol, and identifiable cases of
infectious disease, it is commonly accepted that
smoke and aerosol does present a hazard.
This document is a review of the scientific
literature, recommendations, and regulations
related to surgical smoke for the purpose of
helping healthcare workers make an educated
decision when considering products offering
protection from exposure to surgical smoke.
• Chemicals in surgical smoke are irritants,
mutagenic, cytotoxic, and carcinogenic.6,8
• Patients absorb chemicals through the
peritoneum.6, 16, 17, 31
Potential Health Risks Associated with Surgical Smoke
Hazardous Chemicals
Chemical Analysis
The noxious odor of surgical smoke is a negative
aspect of working in a modern operating room.
In addition to being annoying and unpleasant,
this odor is an indication of the contents of the
smoke. The smell is a conglomeration of chemical
by-products from the burning of proteins and
lipids when using laser or electrosurgical
instruments.1,2 In addition to possible long term
effects, these chemicals cause headaches, as
well as irritation and soreness in the eyes, nose,
and throat.1-4
Smoke generated through the use of lasers and
electrocautery in surgical procedures has been
subject to a variety of differing analytical
procedures. One important method utilizes the
technologies of gas chromatography and mass
spectroscopy to determine the nature and
quantity of the exact chemicals in surgical smoke.
Numerous researchers have analyzed chemical
constituents of surgical smoke. From these
analyses, the following list of chemicals in both
laser and electrocautery surgical smoke has been
compiled in Table 1. 5-11
Potential Health Risks Associated with Surgical Smoke (continued)
Table 1
Chemicals in Surgical Smoke
Acrolein
Butene
Ethyl benzene
Methane
Propene
Acetonitrile
3-Butene nitrile
Ethylene
6-Methyl indole
Propylene
Acrylonitrile
Carbon disulfide
Ethynyl benzene
2-Methyl propanol
2-Propylene nitrile
Acetylene
Carbon monoxide
Formaldehyde
3-Methyl butenal
Pyridine
Alkyl benzenes
Creosols
Furfural
2-Methyl furan
Pyrrole
Benzaldehyde
1-Decene
Hexadecanoic acid
4-Methyl phenol
Styrene
Benzene
2,3-Dihydro indene
Hydrogen cyanide
Methyl pyrazine
Toluene
Benzo nitrile
Ethane
Indole
Phenol
1-Undecene
Butadiene
Ethene
Isobutene
Polyaromatic
Hydrocarbons
Xylene
Regulated Exposure Levels and Health Effects
Many of the specific chemicals listed above are known
to be dangerous. OSHA has set limits for allowable worker
exposure.12 Exposure limits, health effects, and measured
levels of various chemicals in surgical smoke are summarized
in Table 2. The health effects associated with these chemicals
represent exposure in excess of the permissible exposure
limits (PELs) published by OSHA. The purpose of PELs is to
prevent these health effects from occurring and to provide a
safe work environment for persons potentially exposed to
these chemicals.
Table 2
OSHA Chemical Exposure Limits and Associated Health Effects12
Chemical
OSHA Permissible
Exposure Limit
Parts per
Million (ppm)
mg/m3
Acetaldehyde5
200 TWA*
150 STEL**
360
Acetonitrile6
40 TWA
60 STEL
0.1 TWA
0.3 STEL
2 TWA
10 STEL
70
Acrolein5
Acrylonitrile6
Benzene5,9,14,15
1 TWA
5 STEL
Carbon
monoxide16-20
35 TWA
200 STEL
Ethyl benzene9
100 TWA
125 STEL
14
435
Associated Health Effects
Eye, skin, and respiratory-tract irritant. Clinical exposure to vapors also
include erythema, coughing, pulmonary edema, and narcosis. May be
teratogenic. May facilitate uptake of other atmospheric contaminants
by bronchial epithelium. International Agency for Research on Cancer
(IARC) listed as possible carcinogen.
In animal studies, has been found to be embryotoxic and teratogenic in
rodents exposed to levels sufficiently high to cause maternal toxicity.
Irritation of nose, eyes, and the upper respiratory tract, but lung edema
can occur after exposure to high tissue concentrations.
Short-term exposure can cause eye irritation, nausea, vomiting, headache,
sneezing, weakness, and lightheadedness. Long-term has been shown to
cause cancer in laboratory animals and has been associated with higher
incidences of cancer in humans. Repeated or prolonged exposure of the skin
to acrylonitrile may produce irritation and dermatitis.
Irritation in eyes, nose, and respiratory tract, headache, dizziness, and
nausea. Long-term exposure even at relatively low concentrations.
May result in various blood disorders, ranging from anemia to leukemia.
Many blood disorders associated with benzene exposure may occur
without symptoms.13
Carbon monoxide readily combines with hemoglobin to form carboxyhemoglobin
(HbCO) and methemoglobin (metHb). Excessive accumulations of HbCO
and metHb cause hypoxic stress in healthy individuals as a result of
reduced oxygen-carrying capacity of the blood. In patients with cardiovascular
disease, such stress can further impair cardiovascular function.
Irritation of nose, eye, and the upper respiratory tract.
Levels in
Surgical Smoke
DNM***
DNM
4.3 µg/50 mg
DNM
Benzene Soluble
0.7-6.7 mg/m3
0.2-7.4 mg/m3
71 µg/m3
12.8 µg/50 mg tissue
326 +/- 360 ppm
425 ppm (115-2100)
209 +/- 19 ppm
814 +/- 200 ppm
475 ppm (100-1900)
31 µg/m3
2
Potential Health Risks Associated with Surgical Smoke (continued)
Table 2
OSHA Chemical Exposure Limits and Associated Health Effects12 (continued)
Chemical
OSHA Permissible
Exposure Limit
Parts per
Million (ppm)
mg/m3
Formaldehyde5,10
0.75 TWA
2 STEL
Hydrogen
Cyanide10
Polyaromatic
Hydrocarbon;
Naphthalene5
Styrene5,9
10 TWA
4.7 STEL
10 TWA
15 STEL
11
50 TWA
100 STEL
2
Toluene5,9
100 TWA
150 STEL
100 TWA
150 STEL
2
Xylene5
50
435
Levels in
Surgical Smoke
Associated Health Effects
Formaldehyde is highly irritating to upper respiratory tract and eyes.
Concentrations of 0.5 to 2.0 ppm may irritate the eyes, nose, and throat
of some individuals. Formaldehyde is a potential cause of cancer in humans.
Exposure has been associated with cancers of the lung, nasopharynx and
oropharynx, and nasal passages. Rats exposed to formaldehyde at 2 ppm
developed benign nasal tumors and changes of cell structure in the nose as
well as inflamed mucous membranes of the nose. Structural changes in
epithelial cells in the human nose have also been observed.21
Long-term exposure showed increase in symptoms of headache, weakness,
throat irritation, vomiting, dyspnea, lacrimation, colic, and nervousness.
Vapor causes headache, loss of appetite, and nausea. Exposure causes
optical neuritis, corneal damage, and kidney injury.
3.4 µg/50 mg
tissue
0.2-0.8 ppm
Respiratory irritant causing wheezing, shortness of breath, and chest tightness.
A narcotic, and a neuropathic agent causing sleepiness, fatigue, headache,
difficulty in concentration, malaise, nasal irritation, and nausea. ACGIH and
EPA list as possible carcinogens.
Headache, fatigue, lack of appetite, lassitude, temporary amnesia, impaired
coordination, and anorexia. Also a suspected liver toxin.
Headache, fatigue, lassitude, irritability, and gastrointestinal disturbances
as most common symptoms.
21 µg/m3
DNM
100 ppm
3.6 µg/50 mg
tissue
460 µg/m3
DNM
DNM
* TWA: Time-weighted average over 8 hour period
** STEL: Short-term exposure limits for 15 min. period
*** DNM: Detected but not measured
While these studies have measured the individual chemical
concentrations and compared them to regulated exposure
levels, no work has been done to measure the effect of their
combined presence in the smoke on individuals working in the
operating room.
Biologic Analysis
An additional method for analyzing surgical smoke is to
evaluate the mutagenic effect of the smoke condensate on
living cells. Even with the long list of chemicals that have been
identified in surgical smoke, it is suspected there are many
more constituents not identified to this point.2,14,24 For this
reason, some researchers have chosen a biologic approach in
the analysis of surgical smoke. One study measured the effect
of the electrosurgical smoke condensate on MCF-7 human
breast carcinoma cell colony formation and found it caused a
significant reduction. They concluded the smoke is cytotoxic.23
A number of studies have also evaluated the mutagenic effect
of smoke on living cells using the Ames test. It entails the
exposure of two strains of Salmonella typhimurium bacteria to
smoke condensate, followed by observation of the amount of
mutation that occurs in the cells. Three different evaluations of
surgical smoke generated by either laser and electrocautery
have confirmed its mutagenicity.10,24,25 Tomita et al. suggest
the mutagenic potency of electrocautery smoke to be twice
that of laser smoke. The authors compared the amount of
3
mutagenic condensate from cautery of one gram of tissue
is equivalent to three cigarettes for laser and six
cigarettes for electrocautery smoke.25
Hazards to Patients from Chemical Exposure
Absorptive properties of the peritoneum are well documented.
Encompassing more than 2 m2, the peritoneal lining can
absorb osmotic fluids at rates exceeding 30 mL/hr through
transcapillary channels as well as specialized pores measuring
4 to 12 µm.26-29 Absorption is further increased by the
vasodialatory effect of CO2 on the surface vasculature
of the peritoneum and an increase in intra-abdominal
pressure to 15 mm Hg (the usual pressure of laparoscopic
pneumoperitoneum).8,30
The primary concern investigated in the research, related
to the patient’s exposure to surgical smoke, has been the
absorption of carbon monoxide (CO) into the patient’s blood.
The formation of CO is caused by a chemical reaction
between hydrogen ions (produced during combustion) and
carbon dioxide (CO2, used to create the pneumoperitoneum).16
Carbon monoxide readily combines with hemoglobin to form
carboxyhemoglobin (HbCO) and methemoglobin (metHb).
Excessive accumulations of HbCO and metHb cause hypoxic
stress in healthy individuals as a result of the reduced oxygencarrying capacity of the blood. In patients with cardiovascular
disease, such stress can further impair cardiovascular function.12
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Potential Health Risks Associated with Surgical Smoke (continued)
In a series of publications, one researcher has measured
metHb increases from less than 1 to 4.2% and for HbCO from
less than 2 to 18% in a study of 25 patients receiving either
laser or electrocautery laparoscopic hysterectomy or
laparoscopic vaporization of endometriosis; intraperitoneal
CO increased to a mean of 425 ppm within two minutes
(range 115 to 2100 ppm).17 Ninety-six percent of patients
in smoke-producing procedures experienced statistically
increased metHb levels after 15 minutes of surgery; all
patients demonstrated a statistically significant increase at
30 minutes and longer. A third of the patients returned to
baseline levels three hours after surgery; one patient required
six hours to return to baseline. The experimental group
experienced more postoperative headaches, double vision,
muscle weakness, and nausea vomiting. All patients had the
same anesthetic and were matched for age and sex.6,17,31
Other studies measured CO concentrations ranging from
100 to 2100 ppm, with averages all in excess of OSHA
standards for environmental exposure.12,16,18-20
One study took specific steps to prevent the effects of CO on
their patients. They demonstrated that with hyperventilation of
50 to 100% oxygen and the continuous and aggressive
evacuation of intra-abdominal smoke there was no increase in
HbCO and metHb levels and thus no risk of CO poisoning.32
Viable Viruses
As more medical professionals become aware of the dangers
of exposure to human immunodeficiency virus (HIV) and
Hepatitis B virus (HBV), a number of studies have been
conducted to examine virus viability in electrocautery and laser
smoke. There are numerous examples of viable virus being
identified in CO2, ER:Yag, ND:Yag laser and electrocautery
smokes generated at a range of power settings.35-40 One
study demonstrated HIV DNA contained in laser smoke
generated by a CO2 laser remained viable for 14 days.35
They further speculated:
Although we did not examine electrocautery by-products
for the presence of HIV, one could surmise that the smoke
would likely contain HIV DNA. An alarming fact is the
smoke evacuators are not commonly employed in
conjunction with electrocautery and electrosurgical
operations.35
A survey study, in 1994, demonstrated a significantly higher
incidence of nasopharyngeal lesions among CO2 laser
surgeons in comparison to the control group. The presence
of this difference in conjunction with the fact that inhalation of
laser plume is a likely means by which Human Papillomavirus
(HPV) can be transmitted to the upper airway indicates CO2
laser surgeons are at increased risk of acquiring
nasopharyngeal warts through inhalation of the laser plume.41
Finally, a case study was published linking the laryngeal
papillomatosis in an ND:Yag laser surgeon to virus particles
in laser plume from one of his patients.42
While the studies have not been unanimous in their findings,
the majority do support legitimate concern for viable viruses in
surgical smoke. In addition, the aerosol created by ultrasonically
activated (harmonic) devices contains particles of tissue,
blood and blood bi-products of a respireable size.83
Viable Cells
The primary concern behind this work seems to be a
combination of the risk of infection to operating room
staff and concern for dissemination of cancer cells within
the pneumoperitoneum leading to port-site metastasis. Due
to variation in energy levels, surgical device, dwell time, and
testing techniques, the studies to date have been inconclusive.
Numerous researchers, however, have demonstrated that
intact cells and blood components are aerosolized by lasers,
ESUs, and ultrasonic scalpels.39,44-49 Two of these published
studies have concluded the cells remain viable.45,47
One research team, in particular, tested cell viability using both
the trypan blue and MTT assays to determine cell viability in
electrocautery smoke. They found viable cells using MTT and
not trypan blue. They also found lower energy and shorter
bursts were more likely to produce viable cells in the plume.47
In addition to the work described above (which has
investigated the existence of intact cells in surgical smoke) the
liberation of cells in the process of performing laparoscopic
surgery has been considered a plausible vector for port-site
metastasis by many other investigators.39,50-56,82 These studies
measured tumor growth at the port sites. It is speculated,
liberation of cells may also be caused by the manipulation
of tissues with instruments during laparoscopic procedures.
These cells are then transported via gas flow in the
pneumoperitoneum due to leakage at the ports in what has
been called a “chimney” effect.57,58,82 The investigators have
documented metastases at port sites remote to the removal
of the cancerous tissue.39,50-56,82
Nonviable Particles
Regardless of chemical or biologic make-up of surgical smoke
contents, the nature of small particles can also present a
hazard to patients and personnel. Particles in the size range
of 0.5 to 5.0 µm are considered “lung damaging dust” because
they can penetrate to the deepest regions of the lung.59,60
Nezhat et al. measured particle-size ranging from 0.1 to 0.8 µm
when using a CO2 laser.43 Later, DesCôteaux measured the
size range to be 0.1 to 25 µm when using electrocautery.45
Heinsohn et al. measured particles ranging from 0.07 to 0.42 µm
in electrocautery smoke.46 Figure 1 compares these results to
other particle sizes.
Two research teams have conducted studies to determine the
effect of surgical smoke particulate on the lungs. Baggish et
al. demonstrated after long-term exposure, fine particulate
matter resulting from the use of a CO2 laser was deposited in
the alveoli of test animals.61 The presence of these particles
caused congestive interstitial pneumonia, bronchiolitis, and
emphysema.61 These findings were confirmed by Wenig et al.
They documented pathologic changes in the lungs of rats
from both Nd:YAG laser and electrocautery smoke.62 These
findings are not unlike what is expected from long-term
inhalation of other types of particulate matter.63-69
4
Potential Health Risks Associated with Surgical Smoke (continued)
Figure 1
Relative Size of Small Particles
100
10
Human
Hair
Smallest Visible Particle
Tabacco
Smoke
Yeast &
Fungi
Ragweed
Pollen
Nezhatt
(Laser)
1
0.1
0.01
DesCoteaux
(ESU)
Lung Damaging
Dust
Virus
Red Blood
Cells
Bacteria
Heinsohn
(ESU)
HIV
Hepatitis B
Human
Chromosome
0.001
Regulations and Recommendations
Current guidelines and recommendations pertaining to surgical
smoke based on research to date are summarized below:
Occupational Safety and Health Administration (OSHA)
An estimated 500,000 workers are exposed to laser or
electrosurgical smoke each year, including surgeons,
nurses, anesthesiologists, and surgical technologists.
Surgical plumes have contents similar to other smoke
plumes, including carbon monoxide, polyaromatic
hydrocarbons, and a variety of trace toxic gases. As such,
they can produce upper respiratory irritation, and have invitro mutagenic potential. Although there has been no
documented transmission of infectious disease through
surgical smoke, the potential for generating infectious viral
fragments, particularly following treatment of venereal
warts, may exist. Local smoke evacuation systems have
been recommended by consensus organizations, and may
improve the quality of the operating field.70
Although OSHA does not specifically require the use of smoke
evacuation systems, it does regulate staff exposure to a wide
range of substances commonly found in surgical smoke
plume. OSHA has established PELs for many of these
substances. Additionally, OSHA’s general duty clause requires
each employer to:
Furnish to each of his/her employees employment and a
place of employment which are free from recognized
hazards that are causing or are likely to cause death or
serious physical harm to his employees.71
The primary objective is to control occupational diseases
caused by breathing air contaminated with harmful
substances. This is to be accomplished through accepted
engineering controls if feasible, or through the use of
appropriate respirators. *Note: Surgical masks used to
prevent contamination of the patient are not certified for
respiratory protection of medical employees.72
Because blood borne pathogens have been identified in
surgical smoke, the following OSHA regulation also applies:
5
When there is occupational exposure, the employer shall
provide, at no cost to the employee, appropriate personal
protective equipment such as, but not limited to, gloves,
gowns, laboratory coats, face shields or masks and eye
protection, and mouthpieces, resuscitation bags, pocket
masks, or other ventilation devices. Personal protective
equipment will be considered "appropriate" only if it does
not permit blood or other potentially infectious materials to
pass through to or reach the employee's work clothes,
street clothes, undergarments, skin, eyes, mouth, or other
mucous membranes under normal conditions of use and for
the duration of time which the protective equipment will be
used.73
In a document, yet to be released, entitled “Information for
Health Care Workers Exposed to Laser and Electrosurgery
Smoke,” OSHA is expected to place laser and electrocautery
smoke on a more equal level of hazard. This document will
also discuss personnel, workplaces, types of ESUs and
lasers, physical hazards of lasers and ESUs, constituents of
smoke, pathophysiological effects of smoke, infectious
potential of laser and ESU plume, methods of protection,
engineering controls, personal protective equipment,
conclusions, and recommendations.74
American National Standards Institute (ANSI)
Electrosurgical devices and instrumentation often are used
both separately and simultaneously with health care laser
systems. These devices have been found to produce the
same type of airborne contaminants as produced by lasertissue interaction, and these contaminants should be
evacuated from the surgical site.75
In operations that use Class 4 lasers, the vaporization of
target tissue produces laser generated airborne contaminants
(LGAC)… Analysis of the LGAC has shown the presence of
gaseous toxic compounds, bioaerosols, dead and live
cellular matter, and viruses.75
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Regulations and Recommendations (continued)
Association of peri-Operative Registered Nurses (AORN)
Exposure to smoke plume generated during electrosurgery
should be reduced.11
Exposure to smoke plume generated during laser surgery
should be reduced by implementing a variety of engineering
controls.11
The release of gas, electrosurgical smoke, and laser plume
during endoscopic surgery exposes the surgical team to
blood products, fluid, and cellular debris. A system for
evacuation provides protection from eye, nose, and lung
irritations and reduces the risk of exposure to infectious
agents. Patients and peri-operative personnel should be
protected from inhaling the smoke generated during
electrosurgery.11, 76
National Institute of Occupational Safety and Health (NIOSH)
During surgical procedures using a laser or electrosurgical
unit, the thermal destruction of tissue creates a smoke
byproduct. Research studies have confirmed that this smoke
plume can contain toxic gases and vapors such as benzene,
hydrogen cyanide, and formaldehyde, bioaerosols, dead and
live cellular material (including blood fragments), and viruses.
At high concentrations the smoke causes ocular and upper
respiratory tract irritation in health care personnel, and creates
visual problems for the surgeon. The smoke has unpleasant
odors and has been shown to have mutagenic potential.
General room ventilation is not sufficient by itself to capture
contaminants generated at the source (i.e., the surgical site).77
Protection Offered by Masks
Surgical masks do not provide adequate protection to
workers when exposed to laser or ESU smoke.42,72,74
Standard surgical masks are used to prevent crosscontamination from the healthcare provider to the patient. As
demonstrated in various studies, specifically designed masks,
called respirators, are still not absolute barriers and leakage in
the seal of the mask to the face is also a source of penetration.
No studies have measured the effectiveness of these
respirators in removal of chemicals and odor. Table 3 summarizes
the results of various mask evaluations in the literature.
Table 3
Summary of Mask Penetration Studies
Mask Type
Flow Rate
Cone Surgical Mask78
Flat Surgical Mask with Filtration Layer78
Nuisance Dust Respirator78
Dust-Mist Respirator78
Dust-Mist-Fume Respirator78
Sub-micron Surgical79
Dust-Mist Respirator79
Dust-Mist-Fume Respirator79
High Efficiency Particulate Arrestor (HEPA)79
Surgical Mask80
Surgical Mask80
Surgical Mask with Filtration Layer80
Surgical Mask with Filtration Layer80
Full Face Respirator80
Full Face Respirator with 4mm Seal Leak80
Surgical Mask with Filtration Layer81
30 L/min
30 L/min
30 L/min
30 L/min
30 L/min
28 L/min
28 L/min
28 L/min
28 L/min
12.5 L/min
12.5 L/min
12.5 L/min
12.5 L/min
30 L/min
30 L/min
Surgical Mask with Filtration Layer
and Leakage81
Challenge
Particle Size
Organism
Penetration
0.3 µm
0.3 µm
0.3 µm
0.3 µm
0.3 µm
0.5 x 2 µm
0.5 x 2 µm
0.5 x 2 µm
0.5 x 2 µm
0.9 to 1.8 µm
0.9 to 1.8 µm
0.9 to 1.8 µm
0.9 to 1.8 µm
0.9 to 1.8 µm
0.9 to 1.8 µm
0.9 to 1.8 µm
NA
NA
NA
NA
NA
M. chelonae
M. chelonae
M. chelonae
M. chelonae
M. luteus
M. luteus
M. luteus
M. luteus
M. luteus
M. luteus
M. luteus
80%
50%
80%
9%
2%
3%
3%
0.04%
0.01%
11%
73%
5%
3%
1%
5%
5%
0.9 to 1.8 µm
M. luteus
25%
Nuisance Dust (ND) Respirator
Dust is defined as a solid particle formed by crushing or other mechanical breakage of a parent material.
Dust-Mist (DM) Respirator
Mist is a liquid particulate aerosol, typically formed by physical shearing of liquids such as nebulizing, spraying, or bubbling.
Dust-Mist-Fume (DMF) Respirator
Fume is a solid particulate aerosol produced by the condensation of vapors or gaseous combustion products.
6
Conclusion
The variety of laser and electrosurgical instruments used in
today’s operating rooms share one thing in common; they all
generate smoke. We have discussed the four elements of
surgical smoke which present potential health risks to patients
and operating room staff; hazardous chemicals, viable virus,
viable cells, and nonviable particles. The body of literature
reviewed in this document validates the concerns regarding
surgical smoke. It is meant to be a resource, for those people
exposed to surgical smoke, to understand the risk and
choose the best method or product to address their needs.
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